Frequent switching between JAK inhibitors observed in patients with RA
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PHILADELPHIA — Patients with rheumatoid arthritis frequently switched between JAK inhibitors in Australia, according to a presentation at ACR Convergence 2022.
“JAK inhibitors and biologics are government subsidized in Australia and rheumatologists can choose to prescribe whichever agent they feel is most clinically appropriate for their patient,” Sabina Ciciriello, MD, director of the rheumatology department at the Royal Melbourne Hospital and rheumatologist in a private practice at Melbourne Health, said during her presentation.
According to the abstract, uptake of JAK inhibitors has increased with the approvals of tofacitinib (Xeljanz, Pfizer), baricitinib (Olumiant, Eli Lilly & Co.), and upadacitinib (Rinvoq, AbbVie). Therefore, Ciciriello and colleagues wanted to determine the reasons why patients who initiated a JAK inhibitor in the first-line, second-line, or third-line setting switched to either a different JAK inhibitor, a TNF inhibitor or another biologic disease-modifying antirheumatic drug, as well as time to switch and switch patterns.
The retrospective, observational analysis included patients aged 18 to 95 years with a physician diagnosis of RA who began treatment with a JAK inhibitor between October 1, 2015, and September 30, 2021. The data was pulled from the OPAL dataset, a collection of deidentified, aggregated clinical data collected from the electronic medical records of 112 rheumatologists in Australia.
The analysis included 5,900 patients, with 1,875 initiating baricitinib, 3,662 on tofacitinib, and 1,814 on upadacitinib. In the first-line setting for patients on tofacitinib, median persistence was 34.9 months (95% CI 30.9-40.7). In the third-line setting or later for patients receiving upadacitinib, median persistence was 18.8 months (95% CI 18.8-not reached). The median time to switch was shortest for patients receiving upadacitnib, and Ciciriello and colleagues found that in the first-line setting, 50% of switches were from a JAK inhibitor to a TNF inhibitor. However, when looking at all lines of therapy, 30% to 36% of switches were from a JAK inhibitor to another JAK inhibitor. In later lines of therapy, it was more common to see a switch to a biologic DMARD with other mechanisms of action compared with switching from a JAK inhibitor to a TNF inhibitor.
According to the abstract, 22.8% of patients received upadacitinib as monotherapy at the time of switching in the first line setting compared to 35.6% of patients who received baricitinib and 37.6% who received tofacitinib. The researchers also determined that the use of monotherapy increased in the second- and third-line settings for all agents. Finally, the most common reason for switching was “lack of efficacy,” followed by “better alternative,” and “‘adverse reaction.”
The researchers highlighted that since there was limited follow-up, upadacitinib results should be interpreted cautiously.
“This study showed that treatment patterns and persistence were comparable across the three different JAK inhibitors, with median persistence longest when they were used first-line” Ciciriello said. “JAK to JAK inhibitor switching was common, even after a JAK was used in second- or third-line and when lack of efficacy was given as the reason for switching.”
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Ciciriello S, et al. Abstract 0274. Presented at: ACR Convergence 2022; November 11-14, 2022; Philadelphia (hybrid meeting).
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